Provider Demographics
NPI:1508840307
Name:NORTHUMBERLAND COUNTY MENTAL HEALTH MENTAL RETARDATION PROGRAM
Entity Type:Organization
Organization Name:NORTHUMBERLAND COUNTY MENTAL HEALTH MENTAL RETARDATION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-495-2002
Mailing Address - Street 1:217 N CENTER ST
Mailing Address - Street 2:BLDG A
Mailing Address - City:SUNBURY
Mailing Address - State:PA
Mailing Address - Zip Code:17801-2205
Mailing Address - Country:US
Mailing Address - Phone:570-495-2212
Mailing Address - Fax:570-988-4444
Practice Address - Street 1:217 N CENTER ST
Practice Address - Street 2:BLDG A
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-2205
Practice Address - Country:US
Practice Address - Phone:570-495-2010
Practice Address - Fax:570-988-4991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007378070019Medicaid